cognitive and functional rehabilitation in brain injury hilary siebens, m.d. department of physical...
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Cognitive and Functional Rehabilitation in Brain Injury
Hilary Siebens, M.D.Department of Physical Medicine
& Rehabilitation
Harvard Medical School
Spaulding Rehabilitation Hospital
Boston, Massachusetts
Neurosurgical Diagnoses Under Consideration
Brain Tumors Intracranial Hemorrhage
(intraparenchymal and subdural) Severe Traumatic Brain Injury (TBI)
Subarachnoid Hemorrhage Hydrocephalus(primary&secondary)
Pathophysiology
Primary Injurytumor, hemorrhage, diffuse axonal injury,contusions
Secondary InjuryICP, edema, systemic factors (hypoxia, hypotension)
Mechanisms of Functional Recovery
Recovery is believed to occur at multiple levels (from alterations in biochemical processes to alterations in family structure)
Resolution of Temporary Factors Neuronal Regeneration Synaptic Alterations Functional Substitution Learning of New Skills Whyte,Rosenthal 1993
Definitions in Rehabilitation
Disease (atherosclerosis in peripheral arteries)
Impairment - organ level(below the knee amputation)
Disability - person level(inability to walk without a prosthesis)
Handicap - societal level (inability to walk up stairs with prosthesis)International Classification of Impairment,Disease, & Handicap, WHO 1980
Domains of Concern in Rehabilitation
Medical Stability (goal being acute hospital discharge ASAP to right setting with right rehabilitation program)
Understanding of Cognitive Deficits Understanding of Behavioral Issues Physical Performance Deficits Patient’s Living Environment Prevention of Complications(from
cognitive/behavioral/immobility factors)
Element of Time
Recovery/adjustment occurs over a trajectory of weeks, months, and years
Rehabilitation interventions depend on amount of time since injury onset
Medical Stability Issues(1)
Neurological (seizure prophylaxis, agitation)
Cardiovascular (central dysautonomias, HTN,orthostasis)
Pulmonary (aspiration, impaired cough)
Gastrointestinal (swallowing,dehydra-tion,nutrition,GI bleeding,bowel incontinence, elevated LFTs)
Medical Stability Issues(2)
Dermatologic (pressure sores,rashes)
Hematological (anemia,coagulopathy)
Endocrine (pituitary-SIADH/DI, immobilization hypercalcemia)
Genitourinary (infection, incontinence)
Seizure Prophylaxis in TBIRationale
prevention early when seizures may cause greatest harm(prevention of seizure-induced edema )
prevention of loss of employment, accidental injury, loss of driving privileges
medicolegal concerns if not done antiepileptic medications may arrest
epileptogenesis
Seizure Prophylaxis in TBI Risks
cognitive effects significant with phenytoin and phenobarbital and may be greater than carbamazepine (memory etc.)
possible impairment of neurological recovery (documented in animals) in humans during critical periods in recovery
Orthopedic/Musculoskeletal Issues
Spasticityremoval of nocioceptive input therapeutic techniques medications neurolysis
orthopedic procedures neurosurgical procedures
Fractures Heterotopic Ossification (HO)
Cognitive Impairments
Arousal and Attention Learning and Remembering Frontal Executive Function Language Visuospatial Perception and
Construction
Cognitive Remediation
Deemphasis on computer software Deemphasis on rote retraining exercises More naturalistic approach in real-world,
community environment training More holistic approaches produce most
convincing outcome dataJ Whyte,M Rosenthal 1993 in DeLisa JA et al Rehabilitation Medicine-Principles & Practice p.825
Behavioral Impairments
Disruptive, combative, disinhibited behavior
Reduced initiation Depression Awareness Deficits Sexual Dysfunction Social Dysfunction Whyte,Rosenthal 1993
Physical Performance Deficits
Activities of Daily Living (ADLs)
Instrumental Activities of Daily Living (IADLs)
Advanced Activities of Daily Living (AADLs)
Living Environment
Physical (stairs, bathroom layout, community for resource availability)
Social (intimate, family, friend, and community relationships - help or hindrance)
Financial Supports (personal, community)
Treatment Settings for Rehabilitation Management
Acute Care Hospital Acute Inpatient Rehabilitation Hospitals
(Spaulding, etc..) Skilled Nursing Facilities (TCU at SRH, units in
freestanding SNFs) Outpatient Rehabilitation Services (MGH,
SRH, etc..) Home Health Services (MGH SRH HH Agency,
etc.)
Research Frontiers
Medications trend to ABA design rather than
RCT Functional Outcome Measurement
Traumatic Brain Injury Model System Project
Research Frontiers Medications
acute period blocking of neuronal calcium channels
inhibition of free radicalsseizure prophylaxis trials
postacute perioddopamine agonists in low functioning
post -TBIvalproic acid for maladaptive behavior
post -TBI
Research FrontiersFunctional Outcomes
Use of Functional Independence Measure (FIM) from the Uniform Data System (UDS)includes 13 motor itemsincludes 5 cognitive/behavioral items
used in rehabilitation hospitals and some nursing homes
Functional OutcomesBrain Dysfunction - 1990
UDS DataN 2814Mean onset(days) 37Admit FIM(median) 64Discharge FIM(median) 105Mean LOS(days) 42Discharge to Home 80%
Discharge to Acute 7% Granger CV et al Am J Phys Med Rehabil
1995;74:62-66.
Functional OutcomesBrain Dysfunction - 1995
UDS Data Traumatic Non-traumaticN 7,345 4,493
Mean onset(days) 26 28 Admit FIM(median) 60 65 D/C
FIM(median) 101 93 Mean LOS(days) 30 24Discharge to Home 81% 77%
Discharge to Acute 4% 8%Fiedler RC et al Am J Phys Med Rehabil 1997;76:76-81.
Functional OutcomesChanges 1990-1995
Shorter Acute Hospital LOS (37 to 27 days)
Lower Admission FIM (median 64 to 61)
Lower D/C FIM(median 105 to 99)
Shorter Rehabilitation LOS(42 to 28 days)
Same discharge % to Home
Research FrontiersTBI Model Systems Research
Multi-center study of outcomes Results from data set starting to be
published Standard data collection from acute
hospitalization, rehabilitation hospitalization, and one year follow-up Dahmer ER et al J Head Trauma Rehabil 1993;8:12-25.
